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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 45-51

Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan?

1 Department of Transfusion Medicine, Punjab Institute of Cardiology, Punjab, Pakistan
2 Department of Pathology and Transfusion Medicine, DHQ Hospital, Mandi Bahauddin, Pakistan
3 Department of Allied Health Professionals, Directorate of Medical Sciences, Government College University, Faisalabad, Pakistan
4 Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan; Department of Pathology and Blood Bank, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
5 Department of Bioinformatics and Biotechnology, International Islamic University, Islamabad, Pakistan
6 Department of Microbiology and Molecular Genetics (MMG), University of Punjab, Pakistan
7 Department of Pathology, Allama Iqbal Medical College and Jinnah Hospital (AIMC and JHL) Lahore, Punjab, Pakistan

Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Muhammad Saeed
Department of Pathology and Transfusion Medicine, DHQ Hospital, Mandi Bahauddin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/GJTM.GJTM_46_18

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Aims: This study was planned to evaluate the trends of transfusion-transmissible infectious diseases (TTID). Setting and Design: This cross-sectional retrospective study was conducted on donor community attending Transfusion Medicine Department, Punjab Institute of Cardiology, Lahore, Pakistan from January 1, 2012, to December 31, 2016. Subject and Methods: A total of 79,774 blood donors were processed for HbsAg anti-HCV, anti-human immunodeficiency virus (HIV), syphilis, and malaria detection by rapid immune chromatographic technique. Statistical Analysis: The data analysis was done through SPSS 20.0. Chi-square test was employed. Results: Males and females were 91% and 9%, respectively. The mean age was 44 ± 10 years, the prevalence of TTID was 4.0%, and year-wise decreasing trends were observed as 4.4%, 4.2%, 3.7%, 3.9%, and 3.9%, respectively, in 2012–2016. Overall Co-infection was 0.36%, HBV+HCV co-infection was most common. The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9%, 1.7%, 1.1%, 0.1%, and 0%, respectively. Year-wise seroprevalence of HCV was 2.1%, 1.8%, 1.7%, 1.7%, and 1.3%; HBV was 1.2%, 0.8%, 0.8%, 1.0%, and 1.0%, syphilis was 0.8%, 0.8%, 0.9%, 1.4%, and 1.5%, and malaria was 0.1%, 0.03%, 0.1%, 0.1%, and 0.05% in 2012–2016, respectively, and no single case of HIV was detected. Conclusion: Raising trends for syphilis among blood donors underscore the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community.

Keywords: HBV, HCV, human immunodeficiency virus, MP, syphilis, TTID

How to cite this article:
Ahmad M, Saeed M, Hanif A, Waheed U, Arshad M, Ain NU, Rasheed F, Hussain S. Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan?. Glob J Transfus Med 2019;4:45-51

How to cite this URL:
Ahmad M, Saeed M, Hanif A, Waheed U, Arshad M, Ain NU, Rasheed F, Hussain S. Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan?. Glob J Transfus Med [serial online] 2019 [cited 2021 Dec 3];4:45-51. Available from: https://www.gjtmonline.com/text.asp?2019/4/1/45/256760

  Introduction Top

Syphilis has plagued humankind for over 500 years. After the first reported outbreaks struck Europe in 1495,[1] the disease spread speedily to further continents and swelled to a global pandemic. In the mid-twentieth century, penicillin-based treatment became available and infection rates started to decline dramatically. However, strikingly, in the last few decades, infection with Treponema pallidum (TP) has emrged; globally, >10 million cases are reported per annum, adults aged 15–49 years are more prone, and almost 90% of the burden is from developing regions.

Furthermore, in the last eras, syphilis has acquired a new potential for morbidity and mortality through its association with human immunodeficiency virus (HIV). Re-emergence of syphilis is stated from several regions including North America, Western Europe, China, and Australia.[2] Yet, the reason for the resurgence of syphilis is poorly understood. Multiple aspects are involved that drive this burden, such as high-risk sexual activity, vertical transmission, use of contaminated syringes and unsafe blood transfusion. Moreover, immigrations and socio-ecomical changes that limit access to healing also contributes to the cause.[1]

Syphilis is the first transfusion-transmitted infectious disease (TTID) to be screened following implementation of serological screening by blood banks in 1938.[3] Blood transfusion is a significant part of therapeutic and surgical treatments. Although it saves millions of lives, unsafe blood transfusion is a most frequent source of transmission for infectious agents; therefore, screening for TTID is an important part of the blood transfusion.[4] It certifies safe and unsafe transfusions.

Syphilis usually a sexually transmissible disease, while transmission is possible through many other routes i.e vertical transmission, contaminated syringes and contaminated blood transfusions. Malaria as a parasitic disease is caused by Plasmodium species. Pakistan is a moderate malaria-endemic country with annual parasite incidence rate of 1.59.[5] Transfusion based transmissible malaria was first reported in 1911, inspite of multiple steps taken to control the spread of malaria, still it is common Transfusion transmissible infection all over the world.[5]

To study the occurrence of these infectious diseases among the young community, screening of blood donors is used as a surrogate marker. Some drawbacks of the present study includes the exclusion of the individuals below 19 years and above 59 years of age. Moreover the low frequency of female donors in the community accounts for the imbalanced sex-ratio in the study.[6] Therefore, the present study was planned to highlight the emergence of syphilis among TTID among blood donor community of Pakistan, entertained at blood bank PIC Lahore.

  Subject and Methods Top

The ethical committee of Punjab Institute of Cardiology, Lahore, Punjab, Pakistan approved the study protocol. This was a cross-sectional retrospective study. Data was collected from 1st January 2012 to 31st December 2016, a tertiary care cardiac referral center of the province Punjab. A total of 79,774 blood donors of either gender attending Department of Transfusion Medicine, Punjab Institute of Cardiology, Lahore, were included in the study during the period of January 1, 2012–December 31, 2016. During the study duration, all the blood donors who met donor selection criteria and attending Department of Transfusion Medicine, Punjab Institute of Cardiology, Lahore, between the ages of 18 and 60 years were enrolled. Blood donors with the present or previous history of any TTID infection, any surgical procedure, blood transfusion, and pregnancy were excluded from the study. Before serological screening, each donor was screened for physical fitness. Malnourished, apparently unhealthy and anemic blood donors were also deferred.

From each participant, 4 ml of blood was collected (3 ml in yellow-top and 1 ml in lavender-top Vacutainer). yellow top vacutainer was placed in water bath at 37C for blood clotting, centrifugation was done at 3000 rpm for 10 minutes, serum was separated and serological analysis was done. Screening test for MP was performed with whole blood from lavender-top Vacutainer. All laboratory work was done by following the standard operating procedure of this blood bank. Every sample was processed for the WHO-recommended TTIs for our regions (HbsAg, anti-HCV, anti-TP, anti-HIV, and MP) by immunochromatography technique.

Interpretation of results for all the said tests was done after 15 minutes. The test was considered non-reactive when one colored line appeared in the control line region and no line appeared in test line region. If two lines appeared: one colored line in control region and another apparent line in test line region, the test was considered positive. the test was considered to be invalid if control line fails to appear.

All positive samples were re-analyzed for confirmation using the same technique. Written consent was also taken before enrolling the donor.

Data analysis

Statistically, analysis was made using the Statistical Package of Social Services (SPSS) version 20.0 (IBM, USA).

  Results Top

Of the total, 99.9% (n = 79764) blood donors were male who were aged between 18 and 60 years. Decreasing trends were observed for all HBV, HCV, and malaria, while increasing trends were observed in the case of syphilis. The seroprevalence of HCV was 2.1% (n = 333), 1.8% (n = 297), 1.7% (n = 291), 1.7% (n = 259), and 1.3% (n = 227); for HBV, it was 1.2% (n = 184), 0.8% (n = 123), 0.8% (n = 130), 1.0% (n = 185), and 1.0% (n = 170); for syphilis, it was 0.8% (n = 135), 0.8% (n = 149), 0.9% (n = 147), 1.4% (n = 247), and 1.5% (n = 234); and for malaria, it was 0.1% (n = 27), 0.03% (n = 5), 0.1% (n = 25), 0.1% (n = 31), and 0.05% (n = 10) in 2012–2016, respectively. No single case of HIV was detected.

Of 79,774 individuals, only 4.0% (n = 3209) were found positive for any of the TTID screened. In the present study, decreasing trends were observed [4.4% (n = 679), 4.2% (n = 621) 3.7% (n = 599), 3.9% (n = 656), and 3.9% (n = 656)] in 2012–2016, respectively [Figure 1].
Figure 1: Year-wise frequency distribution of total infected blood donors (n = 3209)

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A decreasing trend of HCV, HBV, and HIV and an increasing trend of MP and TP were seen [Figure 2].
Figure 2: Year-wise breakup of TTID prevalence

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The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9% (n = 792), 1.7% (n = 1407), 1.1% (n = 912), 0.1% (n = 98), and 0% (n = 0), respectively. Co-infectivity was 0.36% (n = 288) [Figure 3].
Figure 3: Overall frequency of TTID among blood donors (n = 79,774)

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From the total study population, 0.36% (n = 288) were found positive for co-infection. The most prevalent co-infection was HBV + HCV, followed by HBV + TP, HCV + TP, HCV + MP, and HBV + MP [Figure 4].
Figure 4: Year- and TTID-wise frequency distribution of co-infections

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  Discussion Top

For many decades, syphilis is a stigmatized, disgraceful disease. Each country blamed the neighboring (and sometimes enemy) countries for the outbreak of syphilis. Hence, the residents of today's Germany, United Kingdom, and Italy named syphilis “the French disease,” the French named it “the Neapolitan disease,” according to the Russians concepts it is “Polish disease,” and the Polish called it “the German disease.” The Portuguese, the Danish, and people of Northern Africa called it “the Spanish/Castilian disease.” The Turks coined the term “Christian disease;” furthermore, in North India, the Muslims blamed the Hindu for the affliction and Hindu blamed the Muslims, and in the end, everyone blamed the Europeans.[7]

Overall, only 4.0% of participants were infected with any one or more of TTID, lower than previous studies.[8],[9],[10] This achievement may be attributed to common awareness of health-care providers for reducing the possible risk factors of TTID and also the strict implementation of TTID screening protocols by the state.

Syphilis, which disappeared years ago, has re-emerged in Pakistani youth. The present study reported the prevalence of syphilis to be 1.1%, which is very high as compared to previous studies (0.07%–0.89%).[11],[12],[13] Higher prevalence of syphilis may be attributed to multiple unprotected sexual contacts, improper and excessive use of contaminated injections, intravenous drug intake, and sharing infected household items. The global scenario of incidence of syphilis has been presented by some other studies, where Adjei et al. has reported it to be 7.5% in Ghanaian donors, and Matee et al reports it to be 12.7% in Tanzanian donors.[14],[15] Moreover is lot of published data, indicating that the prevalence of this disease is higher in replacement donors than in voluntary blood donors [13]

Undeniably safe blood is a universal right of all human being; therefore, every donor should be screened for at least recommended TTIDs for each region. The prevalence of these infectious diseases varies from place to place due to variation in standards for medical practices. In Pakistan 1.5 million, transfusions are being made every year.[5] This amplified usage of blood transfusions is resulting from thalassemia, hemophilia, hemodialysis, and as well as road traffic accidents. Hemophilia patients require repeated blood transfusions with a frequency of 1:7000 patients. As the risk of TTID is higher among multitransfused patients,[16] hemophilia and thalassemia patients are more prone to develop TTID which can limit the extent of their life expectancy.

To ensure safe blood for all human beings, all blood bags must be screened for HBV, HCV, HIV, syphilis, and MP.[8] TTID-infected individuals are a major threat for their community; annually up to 16 million individuals are being infected by HBV and 5 million individuals are being infected with HCV around the globe, just because of contaminated blood transfusions.[9] There is always 1% probability of TTID transmission with every blood unit transfusion.[10] This statement enforces to adopt strategies for evaluation and selection and to retain blood donors from low risk for TTID population. As in Pakistan, we are mostly dependent on replacement or family typed blood donors, which donate blood under the influence of society, relations, and cultural traditions, it also boosts the risks for the transmission of TTID.[6]

The present study reported 0% HIV-positive rate, supported by a previous study.[5] From few of last decades, HIV prevalence 37.8% was reported among injectable drug users (IDUs), 7.2% among transgender and 3.1:0.8 among male and female sex workers, respectively.[17] While among general population and pregnant womens HIV prevalence is reported 0.1 & 0.05% respectively.[4] International literature reported 0.66% from Brazil [18] 0.38% India.[19] 0.1% Spain [20] and 0.01%–0.02% in Zhejiang Province (Eastern China was low).[21] Another recent study also reported 0.01% prevalence of HIV.[4]

Our findings for the prevalence of HCV (1.7%) is in agreement with previous reports from Pakistan [22],[23],[24] while this rate is quiet higher than few other studies from Pakistan.[25],[26],[27],[28],[29] However, there exist a varying trend in nationwide studies, which present the decrease in the current prevalence rate, compared to the studies in the last decade.[5],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48] The rapid global extent of HCV infection is primarily due to transmission through blood transfusion and exposure to contaminated medical equipment.

In the case of HBV, very low rate (0.9%) of blood donors were infected in the present study, and a variable rate has been previously reported from the same region (1.1%–8.4%).[4],[5],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[46],[47],[48],[49],[50],[51],[52] Incase of Malaria, present study showed 0.1% Malarial parasitemia, while about 0.1-0.5% is reported from previous studies.[4],[53] This up and down of Malaria prevalences may attributed to difference in geographical areas and climate changes. Moreover to reduce the production of Plasmodium larvae, improvement in sanitation infrastructure, time to time anti mosquito spray, and public awareness programs are needed on regular basis,

The present study reported about 0.36% co-infection, maximum rate was observed for HBV&HCV combination followed by HBV and TP 34.7%, HCV and TP 24.3%, HCV and MP 2.0% HBV and MP 1.3% [Figure 4].

According to data collected from 324 transfusion centers on blood safety, there were 15.4% voluntary non-remunerated blood donation (VNRBD) and 84.6% were replacement or family donations during the year of 2011.[53],[54] TTIDs are commonly detected among paid donors. Many advanced countries have banned the use of paid blood donors. In 1988, the Chinese government banned paid donation, and this resulted in marked reduction in the prevalence of HCV from 8.68% in 1990 and 3.2% in 2010.[55] India also passed a law in 1998; as a result, the prevalence of HBV, HCV, and HIV has declined from 1.62%, 1.85%, and 1.16% in 2004–0.94% and 0.052% and 0.21% in 2009, respectively.[56] In Iran, in 2003, the prevalence of HBV, HCV, and HIV was 0.71%, 0.14%, and 0.0033%, respectively, and it decreased to the frequency to 0.48%, 0.023%, and 0.0031% in 2005. This threat of TTID can only be minimized by appropriately obeying guidelines for selection of blood donors and screening of blood and blood products prior to transfusion with highly specific and sensitive techniques such as enzyme-linked immunosorbent assay or polymerase chain reaction [Table 1].
Table 1: Frequency of hepatitis C virus-positive and hepatitis B virus-positive donors reported in previous studies

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Sexually transmissible infections have complicated human life for centuries. According to a universal estimate, almost 15 million new cases of sexually transmissible infections occur every year. Of these, 4 million affect <20 year olds and 6 million affect 20–24 year olds.[69] Syphilis upsurges the risk of HIV spread by 2–5 times; in addition, co-infection is also very common.[70] Movements in the near past from a neighboring country, gathering, poor sanitation, and untoward sexual behaviors all lead to an amplified prevalence of various diseases, while sexually transmissible infections create a prominent quantity in this regard. Movement of individuals due to war and other factors such as famines, drought, and deporting may unintentionally cause growth susceptibility to syphilis and other sexually transmissible infections. Worsening morality, extramarital sex, low literacy, and cultural reticence for sex education is further compounding the problem. Although there is no vaccine to prevent syphilis, this is curable with a single intramuscular injection of benzathine penicillin G, the first-line drug for all stages of syphilis. This can be reduced by early diagnosis, proper treatment, sex education, and promotion of condom use among infected persons and their contacts are a significant key for syphilis control programs.[2]

  Conclusion Top

Alarmingly increasing trends for syphilis observed among blood donors during the 5-year experience, and the second and third most common co-infections in our study were syphilis with HBV infection, followed by syphilis HCV infections. The growing prevalence of syphilis among the donors underscores the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. Therefore, sexual education and common public awareness programs may increase the safety of blood as well as community; moreover, multiple strategies should be planned on urgent basis, and national and international level approaches are hardly needed for the time to stop this emerging threat on initial phases. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community. However, the graph of other TTIDs is on downward trend which is attributed to hepatitis, malaria AIDS control, and safe blood transfusion programs of the region.

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Conflicts of interest

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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